Comparing Dermatology Referral Patterns and Diagnostic Accuracy Between Non-Physician Providers, Physician Trainees, and Attending Physicians

Abstract

Purpose: With an increasing shortage of physicians in the US, non-physician providers (physician assistants and nurse practitioners) are increasingly serving as primary care providers. We examined the diagnostic accuracy of dermatological conditions by NPPs in contrast to attending physicians (AP) and resident physicians (RPs) using evaluation by board-certified dermatologists. Methods: We analyzed adult patients referred by PCPs at Brigham and Women’s Hospital (BWH) for dermatology consultation at BWH between 01/01/2014 and 03/01/2015. Provider type, patient demographics, and referral reasons were extracted from a referral database. The referral diagnosis was compared to the dermatology diagnosis. Diagnoses were grouped into five major categories: common non-malignant conditions, cancer or suspected cancer, inflammatory, lesion not otherwise specified (NOS), and other. Results: A total of 7,023 patients were referred; 5,448 (77.6%) patients ultimately scheduled an appointment. Of these, all patients referred by NPPs (316) and RPs (214) were analyzed. Of the remaining 4958 patients, 1,008 were randomly selected. The patient populations of the three provider groups differed. NPPs saw more females (71.2%) compared to APs and RPs (57.7% and 63.1%, p<0.001). RPs saw fewer white patients (34.1%) than APs and NPPs (61.1% and 52.8%, p<0.001). Diagnostic accuracy was highest for APs diagnosing common non-malignant conditions (90.8%) compared to RPs and NPPs (78.9% and 76.0%; p=0.002). APs and RPs demonstrated better accuracy in diagnosing cancer or suspected cancer compared to NPPs, although this finding was not statistically significant (37.3% and 39.1% vs. 23.3%, p=0.511). Conclusions: Our data suggests that NPPs in primary care are less accurate in diagnosing common dermatologic conditions and may be less accurate in diagnosing skin cancer (23.3%) compared to attending physicians (39.1%). As dermatologists have diagnostic accuracy rates of 60-80% for melanomas and sensitivity and specificity of 56-90% and 75-90% for non-melanoma skin cancers, there may be room for improvement in the diagnosis of cutaneous malignancies.